UNIT

4 -5: SEARCHING THE EVIDENCE AND PRACTICAL APPLICATION

IN FINDING THE EVIDENCE

At the end of this lecture, the students will be able to:
• 2.2.1 Contrast between different approaches in the process of evidence
based nursing practice.
• 4.2.1 Demonstrate proficiency in using the electronic media and
specialized databases in the process of evidence based practice.
• 5.2.2 Search the internet to find related research articles.

*** This lecture will be assessed on the midterm and final exam, assignment and
research project.



INTRODUCTION
• Evidence can be collected from a variety of sources such as the Internet &
Databases
• Evidence-based Clinical Resources make searching for nursing and medical
information much easier and faster than in past years
• Resources to support evidence-based nursing are rapidly evolving
• Preprocessed sources can be the most practical source of current and
reliable information for front-line staff nurses
• Preprocessed resources are materials that have been reviewed and chosen
based on methodological standards for inclusion
• Evidence comes from many sources, such as Primary evidence, Evidence
summaries, and Translation literature

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1. Primary Evidence
• Primary evidence is usually data collected at the point of patient contact and
can come from:
1. Hospital data
2. Clinical trials
3. Peer-reviewed research journals
4. Conference reports
5. Summaries of information from data sets such as The Center for
Medicare and Medicaid Services’ Minimum Data Set
• Databases used to find this type of information are:
1. MEDLINE
2. CINAHL
3. Library catalogs

2. Evidence Summaries
• Evidence summaries come from synthesized literature and provide broader
focus on topics such as:
1. Systematic reviews
2. Integrative reviews
3. Book chapters
4. Meta-analyses
• Databases for these resources include:
1. MEDLINE
2. MD Consult
3. Library catalogs
4. Online book collections
5. The Cochrane Library
6. Quality improvement and financial information from a topic-
specific database such as Health Business Full Text

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3. Translation Literature
• Translation literature includes quality-filtered Internet and Intranet sources
such as:
1. Practice guidelines
2. Critical pathways
3. Care plans & Clinical innovations
4. Protocols and care Standards
5. Evidence-based practice centers
6. Peer-reviewed journals
7. Bibliographic research databases


SEARCHING THE EVIDENCE
• Searching the evidence include the following steps:
1. Finalizing the answerable question
2. Selecting searchable keywords, synonyms, and related terms from
the answerable question
3. Identifying the best sources to find preprocessed information and
choosing appropriate search tools
4. Developing search strategies and performing the search using
controlled vocabularies, limits, and Boolean operators
5. Evaluating the result set for validity and authority
6. Recording search strategy and saving results

1) Finalizing the answerable question
• Asking the background question according to the problem discussed or the
service that needs improvement or changing
• Asking the foreground question that is more focused and more specific

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2) Selecting searchable keywords, synonyms, and related terms from the
answerable question
• Selecting possible keywords and synonyms from the clinical question should
be the first step in finding the evidence
• Includes keywords based on the question raised in PICO format


EXAMPLES

Example 1: Zinc for children

You are a school nurse visiting an elementary schools of children ages 5 to 13
years in your city. It is the Winter cold and flu season. One of the teachers asks
you about the treatment of the cold and flu. He has heard that zinc lozenges can
help to relieve cold symptoms and is wondering if they really do work and
whether it is okay to give them to the school children

Foreground/ Answerable question
In children with colds, are zinc lozenges safe and effective for relief of cold
symptoms?

PICO
Population/ Patient: Children with colds
Intervention: Zinc lozenges
Comparable Intervention: Other treatments or no treatment
Outcome: Relief of symptoms

Initial search terms (Related terms)
- Zinc Lozenges, zinc acetate, zinc gluconate
- Child Common cold, rhinovirus
- Cold Children, youth

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Example 2: Hip fracture

An elderly patient came to the outpatient clinic suffering from pressure ulcers
two months after having a hip fracture

Foreground/ Answerable question
In elderly patients with hip fracture, what is the effect of nursing care on the
prevention of pressure ulcers?

PICO
Population/ Patient: Elderly people with hip fracture
Intervention: Best nursing interventions
Comparable Intervention: Not applicable
Outcome: Prevent pressure ulcers

Initial search terms (Related terms)
- Elderly, geriatrics, Aged people
- Ulcers, Pressure ulcers, Pressure sores, Wounds
- Patient care, Nursing care, Nursing planning, Nursing management

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Example 3: Osteoarthritis

A 72-year-old woman with osteoarthritis of the knees and moderate
hypertension came to hospital with her daughter who is a nurse. The daughter
wants the doctor to give her mother a prescription for one of the COX-2 enzyme
inhibitors (the enzyme causes inflammation and pain),, because they cause less
GI bleeding

Foreground/ Answerable question
In a 72-year-old-woman with osteoarthritis of the knee, can COX-2 Inhibitor use
decrease the risk of GI bleeding compared with other NSAIDs?

PICO
Population/ Patient: Elderly women with osteoarthritis of the knee and
moderate hypertension
Intervention: COX-2 enzyme Inhibitor
Comparable Intervention: Other NSAIDs
Outcome: Less GI bleeding, pain relief

Initial search terms (related terms)
- COX-2 Inhibitors NSAIDs, aspirin, ibuprofen
- Osteoarthritis Arthritis, therapy
- GI bleeding Gastrointestinal bleeding, stomach ulcers
- Elderly Side effects, adverse effects
- Aged, female

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3) Identifying the best sources to find preprocessed information and
choosing appropriate search tools
• Many information resources are available in electronic formats. Useful Web
sites:

CINAHL
• The Cumulative Index to Nursing and Allied Health Literature (CINAHL)
database covers approximately 2,700 nursing, allied health, biomedical, and
consumer health journals, as well as publications of both the American
Nurses Association and the National League for Nursing from 1982 to the
present
• The database is produced by EBSCO Information Systems and offers various
options, including:
a) CINAHL with Full-Text
b) CINAHL Plus
c) CINAHL Plus with Full-Text
• Each with various depths of coverage and full-text availability
• CINAHL provides references to:
a) Dissertations
b) Standards of practice
c) Book chapters
d) Legal cases
e) Clinical innovations
f) Critical paths
g) Drug records
h) Research instruments
i) Clinical trials

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MEDLINE (PubMed)
• The MEDLINE database, available free of charge through PubMed, is provided
by the National Library of Medicine and is widely known as the premier
source for bibliographic and abstract coverage of biomedical literature
• It includes citation information from a variety of indices that reference more
than 5,000 journals, at least 300 of which are explicit to nursing
• MIDLINE also contains evidence-based filters in its Clinical Queries search
engine
• Clinical Queries uses predetermined clinical filters to find relevant
information topics relating to one of five clinical study categories: therapy,
diagnosis, etiology, prognosis, and clinical prediction guides
• Searches can be sensitive (include most relevant articles but probably include
some less relevant ones) or specific (include mostly relevant articles but
probably omit a few)
• Clinical Queries also includes a search filter for systematic reviews,
combining search terms with citations identified as systematic reviews, meta
analyses, reviews of clinical trials, evidence-based medicine, consensus
development conferences, and guidelines.

The Cochrane Library
• The Cochrane Library is a collection of seven databases used to locate
evidence summaries, or synthesized reviews of health-care interventions,
including the Cochrane Database of Systematic Reviews
• The reviews are highly structured and systematic, including or excluding
evidence based on explicit quality criteria, to minimize bias
• Cochrane Reviews are based on the best available information about health-
care interventions
• They explore the evidence for and against the effectiveness and
appropriateness of treatments (medications, surgery, education, etc.) in
specific circumstances.
• Cochrane reviews address clearly formulated questions such as:

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 - Does fluoride help prevent tooth decay in children?
- Can antibiotics help in alleviating the symptoms of a sore throat?
• Abstracts of reviews are available free of charge from the Cochrane Web site;
however, full reviews are available by subscription.
• The Cochrane Library can be a solid source for locating evidence-based
interventions in nursing practice


Summary of other sources
1. Online Journal of Clinical Innovations:
www.cinahl.com/cexpress/ojcionline3/index.html
2. The Cochrane Collaboration: www.cochrane.org/index.htm
3. Cochrane Collaboration Hand Search Manual
www.cochrane.org/resources/hsmpt1.htm
4. CRISP: Computer Retrieval of Information on Scientific Projects:
http://crisp.cit.nih.gov
5. EBN Online, Evidence Based Nursing: http://ebn.bmj.com
6. EBSCO Publishing:
www.ebscohost.com/thisSubject.php?marketID=2&subjectID=8
7. Joanna Briggs Institute: www.joannabriggs.edu.au
8. Journal of Nursing Scholarship:
www.nursingsociety.org/publications/JNS_main.html
9. NANDA International Taxonomy II: www.nanda.org/html/taxonomy.html
10. NGC—National Guidelines Clearinghouse: www.guideline.gov
11. PubMed: www.ncbi.nlm.nih.gov/sites/entrez?db=PubMed
12. PubMed Central Home Page: www.pubmedcentral.nih.gov
13. Registry of Nursing Research—Virginia Henderson International Nursing
Library: www.nursinglibrary.org/portal/main.aspx
14. TRIP Database: For Evidence Based Medicine (EBM):
www.tripdatabase.com/index.html
15. UpToDate: Putting Clinical Information Into Practice: www.uptodate.com

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16. Worldviews on Evidence Based Nursing:
www.blackwellpublishing.com/journal
Clinical Queries
4) Developing search strategies and performing the search using specific
vocabularies, limits, and Boolean operators
Search Strategies
1. Identifying the resource that will help answer the practice question (CINHAL,
MIDLINE)
2. Break the defined question into individual concepts (Treatments,
Management, Administration, Medications, Pain)
3. Select words and phrases that describe the concepts by using specific
vocabulary for keywords and phrases
4. When the correct term/word/vocabulary is identified, most of the
information is grouped together, saving the time of having to search all the
other synonyms for that term
5. Use the Boolean operators AND, OR, and NOT
6. Combine keywords and phrases with to produce a promising result set
7. Because of differences in American and British spelling, think of alternate
spellings, such as tumour versus tumor, behaviour versus behavior, and
gynaecology versus gynecology
8. Some databases have mapped the terms together to be synonymous while
searching, but many have not
9. Use limits where appropriate, such as age, date of publication, and language
10. Search more efficiently by using filters designed to exclude extraneous
retrievals, for example, limiting by the research publication type will pull
randomized controlled trials or clinical trials into the result set.
11. An initial limit of English only, last 5 years, and nursing subset can greatly
reduce the number of citations

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5) Reviewing and Evaluating Search Results for validity and authority
• The final step in finding the evidence involves reviewing the results to
determine whether they are relevant to the EBP question, and then modifying
the search strategy if necessary
• Each database usually offers a variety of formats and references for review
• If a citation meets the needs of the topic, many databases offer a Related
Articles or Find More Like This feature to help locate similar articles
• If the results are too specific, the Boolean operator OR can broaden the
search
• If the results are too broad, the Boolean operator AND can narrow the results.
Figure 5.3. Boolean OperatorsFigur.4. Setting Limits
Questions to ask when reviewing search results:
1. Who wrote it?
2. Who sponsored the research?
3. What institutional or organizational affiliation exists?
4. When was it published?
5. Has it been reviewed? If so, by whom?
6. Why was it published?
7. Has it been cited? Whom does it cite?

6) Recording search strategy and saving results
• Keep a record of the search strategy and the results
• Permanent searches are useful for individuals who want to periodically re-
execute a search strategy as the database is updated, thereby keeping current
with the literature
• Databases will usually allow researchers to save the results, and some
databases allow users to save the strategy with it
• For those databases that don't provide this function, simply view the strategy
within the database and then copy and paste it into a document
• Many databases allow researchers to save a strategy within the database and
receive update alerts

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• PubMed does this with MyNCBI
• Result sets can also be e-mailed to the user or a colleague, or saved in
bibliographic management programs such as End Note or Reference
Manager
Figure 5.5. Saving a Search

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